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Bakground: Growing educational disparities in mortality due to suicide, drug overdose, or alcohol-related liver disease – or “deaths of despair” (DoD) – have received increased attention in research and public debate. However, no study has investigated educational differences in despair-related mortality outside of North America. Thus, the aim this study was to investigate changes in the association between academic achievement in compulsory school and subsequent all-cause mortality (ACM) and DoD between 1990 and 2018 in Swedish youths.

Data and methods: Register data on all students graduating from compulsory school in Sweden between 1990 and 2010 were used (N = 2 252 938). Students were followed for a maximum of 8 years using discrete time proportional hazard models. Academic achievement was measured by grades at the end of compulsory school.

Results: ACM declined for medium/high achieving but not for low-achieving youths, while DoD increased slightly for medium/high achieving and markedly for low-achieving youths, resulting in growing achievement-related disparities in both types of mortality. The trends were primarily driven by native-born youth and girls.

Conclusions: The trends in Swedish youths resemble the trends in the American working-age population, but partly contrasts with corresponding trends in other European countries. Future research should investigate if the underlying causes that have been emphasized in the American context – socio-economic transformations and a greater supply of drugs – have also contributed to the Swedish trends.

Background: Rising rates of internalizing disorders and rising rates of school failure among adolescents are growing concerns. Despite the strong association between academic achievement and internalizing disorders, possible links between these two trends have not been investigated. Thus, the aim of this study was to investigate the development of the cross-sectional associations between academic achievement and internalizing disorders in Swedish students aged 16 years between 1990 and 2018.

Methods: Register data on specialist psychiatric care and prescriptions of psycholeptic and psychotropic drugs were linked to data on students’ school grades in the last year of compulsory school. The total sample size was 3,089,674 students. Logistic regression models with internalizing disorders as the dependent variable, and graduation year and academic achievement as independent variables, were estimated.

Results: Throughout the period, there was a strong negative association between academic achievement and internalizing disorders. Low-achieving students had by far the highest risks of internalizing disorders. In absolute terms, the increase in internalizing disorders was clearly largest for low-achieving students. The relative risks for low-achieving compared to higher achieving students increased between 1990 and 2010 and declined after 2010.

Conclusions: This study found consistently large, and at least until 2010 growing, achievement-related inequalities in internalizing disorders among Swedish adolescents between 1990 and 2018, with the lowest achieving students having disproportionally high risks. The increasingly pronounced concentration of internalizing disorders in the lowest rungs of the achievement distribution suggests that preventive interventions should focus on supporting this doubly disadvantaged group of students.

Background: Low academic achievement and low educational attainment in adolescence is associated with higher risks of internalizing disorders later in life. However, less is known regarding if these associations vary over time across cohorts. The aim of this study was to investigate temporal changes in the association between academic achievement or educational attainment and subsequent inpatient treatment for internalizing disorders among Swedish youths.

Methods: Register data on all students graduating from compulsory school in Sweden between 1990 and 2010 (N = 2 252 703) were used. Students were followed for a maximum of 8 years using discrete time proportional hazard models. Internalized disorders were measured by specialized inpatient psychiatric care for depression or anxiety disorders. Academic achievement was measured by grades at the end of compulsory school, and educational attainment by completion of upper secondary school.

Results: The positive association between inpatient treatment for internalizing disorders and both low compulsory school achievement and non-completion of upper secondary school became stronger in more recent cohorts. The results were completely driven by girls and native-born youth.

Conclusions: Low compulsory school achievements and failure to complete upper secondary school has become more important risk factors for inpatient treatment for internalizing disorders, particularly in native-born youth and girls. More research is needed to establish whether youth with internalizing disorders increasingly fail in school or whether low achievement has become more harmful for mental health.

Background and aims: According to recent criticism, survey-based measures of adolescent psychosomatic complaints have poor content validity insofar as they conflate trivial with severe complaints. It is argued that this means that estimates of prevalence and trends in complaints may reflect trivial complaints that are not indicators of health problems. In this study, two observable implications of this criticism were investigated: (a) that self-reported psychosomatic complaints should have a bimodal distribution; and (b) that the increase in complaints over time should be of approximately equal size throughout the distribution of complaints.

Methods: Three decades (1985/1986–2017/2018) of repeated cross-sectional data from the Swedish Health Behaviour in School-aged Children survey were used. Psychosomatic complaints were measured using the screening instrument Health Behaviour in School-aged Children symptom checklist. Histograms, bar charts and quantile regression models were used for the analysis.

Results and conclusions: With regard to the first implication, the results showed that the distribution of complaints was not bimodal and that there were no clusters of respondents. This suggests that binary categorisations of students can be reductive and conceal important variations across students. With regard to the second implication, the results showed that the increase in complaints was greatest among students who report frequent and co-occurring complaints. This suggests that reports of increasing complaints in adolescents cannot be explained as being primarily due to a greater inclination to report trivial complaints. It is concluded that any conflation of trivial and more severe complaints in surveys of psychosomatic complaints is not reflected in population-based estimates.

Recurrent pain is an increasing public health problem among school-aged children, with potential negative impact on children's daily lives, such as schoolwork. The overall aim of this study was to investigate whether recurrent pain in school year 6 was associated with poorer academic achievement at the end of elementary school in school year 9. The study was a follow-up study based on data from "The Study of Health in School-Aged Children from Umeå". Participants were 1567 children aged 12 to 13 years who attended school year 6. A follow-up was performed in school year 9, when the children were 16 years old. The children answered a questionnaire about recurrent pain (headache, stomachache, and backache). Information about academic achievement was collected from school registers. The results showed that having weekly recurrent pain in school year 6 predicted lower final overall grade points in school year 9 than in children with no recurrent pain. This applied for recurrent headache, stomachache, backache, and multiple pains and for both girls and boys. Recurrent pain did not predict secondary school eligibility, however. Perceived problems with academic achievement and problems with concentration partly mediated the association between recurrent pain and lower final overall grade points. Sleep problems were not associated with academic achievement and were therefore not a mediator. Thus, the results suggest that recurrent pain may predict later impairment of academic achievement and that problems with concentration and children's perceived achievement in school, but not sleep problems, may partly explain this relationship.

Education reforms that entail increased emphasis on high-stakes testing, assessment and grading have spread across education systems in recent decades. Critics have argued that these policies could have consequences for stress, identity, self-esteem and the overall health of pupils. However, these potentially negative consequences have rarely been investigated in a systematic and rigorous way. In this study we use a major education reform in Sweden, which introduced grades and increased the use of testing for pupils in the 6th and 7th school year (aged 12 to 13 years), to study the consequences of grading and assessment for health outcomes. Using data from the Health Behaviours of School-Aged Children Survey, we find that the reform increased school-related stress and reduced the academic self-esteem of pupils in the 7th school year. This, in turn, had an indirect effect on psychosomatic symptoms and life satisfaction for these pupils. Moreover, the negative effects of the reform were generally stronger for girls, thereby widening the already troubling gender differences in health. We conclude that accountability reforms aimed at increased use of testing, assessment and grading can potentially have negative side effects on pupils’ health.

Students' sense of belonging at school has declined across the world in recent decades, and more so in Sweden than in almost any other high-income country. However, we do not know the characteristics or causes of these worldwide trends. Using data on Swedish students aged 15–16 years from the Programme for International Student Assessment (PISA) between 2000 and 2018, we show that the decline in school belonging in Sweden was driven by a disproportionately large decline at the bottom part of the distribution, and was greatest for foreign-born students, students from disadvantaged social backgrounds, and for low-achieving students. The decline cannot be accounted for by changes in student demographics or observable characteristics related to the school environment. The decline did, however, coincide with a major education reform, characterized by an increased use of summative evaluation, and an overall stronger performance-orientation.

Background: This study was conducted in a general population of schoolchildren in Sweden, with the aim to assess the psychometric properties of a generic preference-based health related quality of life (HRQoL) instrument, the Swedish Child Health Utility 9D (CHU9D), among schoolchildren aged 7–15 years, and in subgroups aged 7–9, 10–12 and 13–15 years.

Methods: In total, 486 school aged children, aged 7–15 years, completed a questionnaire including the CHU9D, the Pediatric quality of life inventory 4.0 (PedsQL), KIDSCREEN-10, questions on general health, long-term illness, and sociodemographic characteristics. Psychometric testing was undertaken of feasibility, internal consistency reliability, test–retest reliability, construct validity, factorial validity, concurrent validity, convergent validity and divergent validity.

Results: The CHU9D evidenced very few missing values, minimal ceiling, and no floor effects. The instrument achieved satisfactory internal consistency (Cronbach’s Alfa > 0.7) and strong test–retest reliability (r > 0.6). Confirmatory factor analyses supported the proposed one-factor structure of the CHU9D. For child algorithm, RMSEA = 0.05, CFI = 0.95, TLI = 0.94, and SRMR = 0.04. For adult algorithm RMSEA = 0.04, CFI = 0.96, TLI = 0.95, and SRMR = 0.04. The CHU9D utility value correlated moderately or strongly with KIDSCREEN-10 and PedsQL total scores (r > 0.5–0.7). The CHU9D discriminated as anticipated on health and on three of five sociodemographic characteristics (sex, age, and custody arrangement, but not socioeconomic status and ethnic origin).

Conclusions: This study provides evidence that the Swedish CHU9D is a feasible, reliable and valid measure of preference-based HRQoL in children. The study furthermore suggests that the CHU9D is appropriate for use among children 7–15 years of age in the general population, as well as among subgroups aged 7– 9, 10–12 and 13–15 years.

The well-being of young people in relation to their school performance has received increased attention in recent years. However, there is a lack of knowledge about the longitudinal and reciprocal relationship between adolescents’ subjective well-being and their academic achievements. The current study examined the bidirectional relationship between subjective well-being and academic achievement across two timepoints (T1 and T2) during the course of mid to late adolescence, i.e.,in school year 9 (age 15), and school years 11–12 (ages 17–18). The study also investigated variation in the association as afunction of adolescent gender. Data on subjective well-being and teacher-assigned school grades of 723 adolescents (48.7% girls) residing in Sweden were analyzed by estimating a series of cross-lagged path models. The findings suggest gender differences in the relationship as no associations were found among boys. Support for a bidirectional relationship between the constructs was only found for girls. For girls, higher subjective well-being at T1 was associated with higher academic achievements at T2, while higher academic achievements at T1 was associated with lower subjective well-being at T2. These findings highlight that the subjective well-being of adolescent girls may be important for their ability to perform at school, but their academic achievements may also inflict negatively on their subjective well-being.

Objectives: To examine health-related quality of life (HRQoL) in young children with low language or congenital hearing loss and to explore the value of assessing HRQoL by concurrently administering 2 HRQoL instruments in populations of children.

Methods: Data were from 2 Australian community-based studies: Language for Learning (children with typical and low language at age 4 years, n = 1012) and the Statewide Comparison of Outcomes study (children with hearing loss, n = 108). HRQoL was measured using the parent-reported Health Utilities Index Mark 3 (HUI3) and the Pediatrics Quality of Life Inventory 4.0 (PedsQL) generic core scale. Agreement between the HRQoL instruments was assessed using intraclass correlation and Bland-Altman plots.

Results: Children with low language and with hearing loss had lower HRQoL than children with normal language; the worst HRQoL was experienced by children with both. The lower HRQoL was mainly due to impaired school functioning (PedsQL) and speech and cognition (HUI3). Children with hearing loss also had impaired physical and social functioning (PedsQL), vision, hearing, dexterity, and ambulation (HUI3). Correlations between instruments were poor to moderate, with low agreement.

Conclusions: Children with low language and congenital hearing loss might benefit from interventions targeting overall health and well-being, not just their impairments. The HUI3 and PedsQL each seemed to provide unique information and thus may supplement each other in assessing HRQoL of young children, including those with low language or congenital hearing loss.